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When he saw the pictures from Abu Ghraib, medical ethicist and practicing physician Steven Miles immediately wondered: Where were the doctors, nurses, and medics while these abuses were happening?

Answering this question led him to read some 35,000 pages of government documents, including testimony, e-mails, autopsies, and internal investigations, all released in response to an ACLU lawsuit under the Freedom of Information Act (FOIA). Miles then meticulously integrated his review of this evidence with the conclusions of investigations conducted by the mainstream press and international human rights organizations. The result is Oath Betrayed.

This extensively cited (though, frustratingly, index-less) book focuses on torture at U.S.-run prisoner detention sites in Iraq, Afghanistan, and Guantánamo Bay. These sites are microcosms of the war on terror generally, in concentrated form: violent, racist, and run with neoliberal incompetence. Miles documents physicians in Iraq reusing gloves and syringes because they lacked adequate supplies; he shows that tuberculosis screening in U.S.-run prisons is worse than it was under Saddam (with sanctions); and he explains that corrupt private food contractors did not supply the meals they were paid for, that food they did bring was filled with bugs and dirt, and that prison commanders did not have the authority to enforce contracts with private suppliers.

Against this backdrop of corruption and neglect, medical personnel were integrated into the interrogation structure, through what Miles calls an unprecedented role for Behavioral Science Consultation Teams (BSCTs—“biscuits”), which included psychiatrists and psychologists. At Camp Na’ma in Iraq, according to an intelligence officer, “every harsh interrogation was approved by the [commander] and the Medical prior to its execution” (55; emphasis in the original memo).

Psychologists’ and psychiatrists’ involvement in interrogational BSCTs led them to identify with the interrogation process. Miles describes, “Behavioral clinicians reportedly micro-managed some interrogations; one anal Guantánamo psychiatrist suggested rationing toilet paper to seven sheets per day and limiting water for bathing” (55–56). Elsewhere, Miles presents the reaction of Navy medic Petty Officer Blay to beatings he witnessed: medical clinicians helped “the prisoners ‘to know that these people were now in charge.’ He did not report the beatings because he felt they were reasonable” (121).

The BSCTs were only one element of a prison medical system that often seemed to have more to do with repression than with healing. When the United States took power in Iraq, it put Hussain Majid, the medical director of Abu Ghraib under Saddam Hussein, in charge of the prison’s “common criminals.” One hundred and twenty pages into the book, Miles gives the answer to his original question about where the doctors and medics in Abu Ghraib were: they were there, they saw what was happening, they did not report it, and they were never punished.

Miles finds that medical professionals have been complicit with torture consistently, in many capacities, at every site of the war on terror. Collectively, doctors and medics have failed to report torture they witnessed firsthand, or clear evidence that they saw in the brutalized bodies of prisoners. They have allowed autopsy reports to be falsified to hide murder and abuse, have handed detainees’ medical records over to interrogators, and have advised interrogators on how to “break” prisoners. They have turned medical examinations into moments of torture, as with the medic who let the notorious Abu Ghraib offender Charles Graner stitch up the Iraqi face he’d just sliced open for sport (125); or when another medic let a soldier use a medical exam as a pretext for sexual assault (135).

The Difficulty in Documenting Dehumanization

The book’s force comes from the accumulation of horrific details like this, which makes it impossible to deny the scope and depth of the problem Miles is documenting. This is despite the limitations of the evidence available to him. Although the U.S. government has had to release a mountain of evidence of its own wrongdoing, it has kept much hidden from view. All interrogation logs remain classified—except one, a leaked journal by psychologist John Leso, who documented, over fifty days, the torture of Mohammed al-Qahtani at Guantánamo. Neither Leso nor any of the many other medical professionals who witnessed his treatment appear to have mounted any complaint—though ultimately the FBI did. No other interrogation logs are available. Neither is much documentation on the treatment of women and children prisoners, even though it is known to exist; Miles suggests that this information is being intentionally suppressed, as the pictures of women being sexually abused at Abu Ghraib have been. It is worth bearing in mind that the horrors Miles is able to document are the parts the government has decided it would release under FOIA challenge.

The flipside of this assemblage of stories, however, is a danger of them becoming generic. This is exacerbated by government censorship: the documents Miles accessed are heavily redacted fragments of what has happened to the people involved. This can make reading the book a strange experience. We are reading about tremendous acts of dehumanization, but we rarely have much detail that would humanize the victims for us. The very accumulation of moral outrages that gives the book its strength also produces a kind of disconnect, as the stories can become all too normalized.

This problem isn’t unique to this book. It is a problem of portraying extreme dehumanization in general: how can you convey the commonplaceness of cruelty without making cruelty itself commonplace? Even the Abu Ghraib pictures, which stunned the world with their grotesque brutality, can lose their power to force you to think about the people involved. At one point, Miles quotes one of the prisoners (arrested for car theft) who experienced the torture portrayed in the photographs from Abu Ghraib: “He put his whole weight on my head and on my knee. I was screaming and crying….I wanted to kill myself….I felt humiliated but I had nothing to kill myself with” (119–20). The photographs don’t convey screaming and crying. Even the prisoners’ faces are hooded from view. The pictures have become so iconic that it takes a new detail—like this short description of the actions and feelings of a prisoner—to shock us back into imagining the scene.

Many of the details in Oath Betrayed serve this function. Miles depicts the beatings and humiliation of one woman at Abu Ghraib, including being stripped in front of male soldiers and her own nephew. When she described her beatings to doctors, one remarked “that it ‘looks like you were run over by a guard’ and to thank God her brain was not injured” (124). Reading these stories is surreal. In the margin next to that one, I wrote that it was like a horror movie—an ironic remark, since, Miles points out, “Americans are fascinated with images of torture even though we carefully keep its frightful reality at a distance. Our favorite form of voyeurism is fictional torture…[and] the same corporations that produce movies primly sanitize torture for their news shows” (19–20).

The difficulty in piecing together stories from censored documents isn’t Miles’s fault, of course, and he does an excellent job of providing an overview of medical complicity in violence and torture. He provides humanizing details—names, ages, occupations, and quotes from torture victims or their survivors—whenever he can. These passages are the most affecting in the book. For example, Miles follows the story of Dilawar, “a twenty-two-year-old farmer and taxi driver, whom American soldiers tortured to death over five days at Bagram Collection Point in Afghanistan in December 2002” (68). He describes the torture that resulted, according to eventual coroner testimony, in Dilawar’s legs being “pulpified” and his body looking like it had been “run over by a truck” (69). In telling the story of Dilawar’s death, Miles explains that another prisoner had died at the same facility in almost the same way, six days earlier; that the military produced multiple death certificates and told reporters Dilawar had died naturally of heart disease; and that he left behind a wife and two daughters.

Miles can do this because Dilawar’s is one of very few cases in which, confronted by reporters who had tracked down the conflicting death certificates, the army pressed charges against some of the soldiers involved. Elsewhere, Miles describes reporters’ obsequiousness in most Pentagon briefings, leading us to wonder just how many Dilawars have had their deaths ignored.

Where Does Torture Come From?

The accumulation of evidence in Oath Betrayed demolishes the idea that, if medical professionals have sometimes failed to live up to their ethical responsibilities at U.S. detention sites, these are isolated individual failures. Miles shows that medical personnel’s role as investigative arms of the war on terror—as opposed to providers of health care—was created from the top down, through the extensions of the BSCT program. So was the idea that basic standards of humane treatment, such as the Geneva Conventions, do not apply. And so was the racism and cruelty at the heart of these policies—Miles cites documents quoting the then-commander of ground forces in Iraq, General Ricardo Sanchez, saying of a group of detained Iraqis, “Why are we detaining these people? We should be killing them” (50).

Given this lead from the top, the consistency of medical abuse across the sites of the war on terror—what Miles calls “an administratively coherent archipelago of facilities stretching around the world” (152)—is not surprising. But it does pose fundamental questions: Why are doctors, ostensibly charged with caring for people, so easily able to become their abusers? And is this inevitable?

These questions reveal a contradiction at the heart of the book. There is no way to read this book and believe that torture (and medical complicity with it) can be blamed on a few “bad apples.” Every page shows that the problem is systemic. Drawing on prior research into Nazi doctors, Miles notes that “physician-torturers do not have a unique psychological profile” (29) and implicates the societies that produce them. In a powerful concluding passage, Miles argues that “the ostensible purposes of torture are rationalizations used by a society that has decided that torture is morally permissible and politically desirable,” and he roots it instead in the political need for a “mirrored netherworld” of dehumanized, supposedly omnipresent enemies (161).

Yet Miles also believes that there is a legitimate role for medical professionals in military interrogations, limited to “train[ing] an interrogator in rapport-building skill and cross-cultural communication” (66). Miles’s target is not U.S. imperialism. He repeatedly argues that torture ultimately harms legitimate U.S. national security and intelligence-gathering efforts. It would be a mistake to see his own opposition as rooted solely in these “pragmatic” concerns; nearly every page conveys his disgust for what torture is doing to the lives of its victims and to the souls of its perpetrators. But because he accepts a legitimate role for the United States in holding and interrogating prisoners in the name of fighting terrorism, he does not penetrate deeply into the political and military conditions that lay the groundwork for torture.

We are left with a kind of institutional variation on the bad apples argument: medical abuse is systemic—but the medical-military system can be restructured to avoid it. Yet it is impossible to imagine one part of the U.S. government violently occupying Iraq, while another provides decent health care and protection to the Iraqi people. The violence of occupation is the main source of the Iraqi people’s need for medical care; the medical adjuncts of that occupation cannot be the source of that care as well. Miles himself states that “a torturing society must secure the passive assent or active complicity of its professions” (164). He follows the doctor Robert Jay Lifton, who studied medical involvement in torture in Nazi Germany, in directing our attention to “atrocity-producing situations” (160).

But imperial occupations are, in and of themselves, atrocity-producing situations. There is no way to control Iraq, or Afghanistan, against the will of its people without attempting to terrorize them out of resisting, and without using extreme racism to get the soldiers and populace of the imperial power to go along. Those are the conditions that produce torture. That means that, one way or another, this occupation seems destined to produce travesties of medical ethics, as long as medics have a role to play in it.

These violations of medical ethics need not be limited to the treatment of Iraqis, as demonstrated by the wounded soldiers being judged medically fit for further tours in Iraq by doctors serving an overstretched military. And nor is the U.S. government’s politicization of doctors limited to those on its own side: recall that the first target of the November 2004 assault on Fallujah was the hospital, with the U.S. claim that it had inflamed the insurgency with “inflated” casualty counts the previous April.

Medical Resistance

But the occupation can produce resistance from medical professionals as well. One avenue for this resistance, discussed extensively in the book, is civilian professional associations. Oath Betrayed not only documents this opposition, but has contributed to it: its publication helped spark psychologists to begin a campaign for a stronger professional stance against participation in interrogation at the American Psychological Association conference last August. Miles points out that professional associations are lobbying organizations, at times reluctant to alienate their allies in the government. But medical professional groups can also be important sites of political opposition (as in, for example, the recent refusal of many doctors to participate in executions in domestic U.S. prisons).

But there is another avenue for medical resistance to torture and brutality, and that is the soldiers’ resistance, particularly to the war in Iraq. Miles briefly mentions clinicians who mounted complaints about the treatment of prisoners, or struggled to find ways to treat Iraqis outside the approved standards of procedure. More generally, the medical arms of the military are not cut off from the general features of occupation that are compelling soldiers to resist.

Indeed, military medics may resist in greater numbers. I have not seen any attempt to analyze whether some groups of soldiers are more likely to resist than others. But after reading Oath Betrayed, I began to notice how many of the public resisters of the Iraq war were medics in Iraq, or were trained as medics back at home.

Augustin Aguayo was recently sentenced to eight months in military prison for refusing to return to Iraq. He had served as a medic there, never loading his weapon because he did not support the war. Kelly Dougherty, the executive director of Iraq Veterans Against the War (IVAW), signed up to be a medic, but was involuntarily made a military police officer in Iraq. Jose Vasquez, the president of the New York City chapter of IVAW, was similarly trained as a medic, although he never served in Iraq. Chanan Suarez-Díaz, president of Seattle’s IVAW chapter, went to Iraq despite opposing the war, partly because he believed that as a medic, he could still help people there. Seeing that he was wrong (and witnessing the lack of the most basic health measures available to Iraqis under occupation), he helped to lead his platoon in refusing an order they disagreed with. Conversely, another IVAW member, in Wisconsin, told me that as a military pharmacist in Iraq, he had treated Iraqis as well as U.S. soldiers—and that for him, this had helped to humanize the people being occupied. A perusal of the IVAW Web site reveals more medic resisters. Beyond their expectations of doing good and their interactions with Iraqis, medics might turn against torture by seeing what it does to its perpetrators; as Miles notes, “Abu Ghraib medics were providing Prozac and starting Alcoholics Anonymous groups for soldiers in the abusive units” (18).

Certainly, this is anecdotal. No doubt medics, like all other groups of soldiers, have varying political views and experiences of war. But it suggests that the same feeling that drove Miles to write his book—being struck by the contradiction of people trained to heal doing its precise opposite—may be felt by those people themselves, and may drive some of them to resist.